I was asked by Dr.
Todd, coordinator of the International Family Medicine Fellowship to share some
of my thoughts and impressions. Here is
an edited version of that synopsis of my time here so far. He wanted to know about my welcome, housing,
the hospital, the spiritual flavor of things…
But before I begin,
I must interrupt myself to say, I saw blue sky today! It was the first time all week! Every day has been gray. We have had two amazing thunder, lightning
and pouring rain storms - rain like I've only seen around tornado and hurricane
season! The rain storms lowered the
temperature, and after having two of the hottest days of the year, the last few
days have been so comfortable. Warm, but
with a welcomed breeze.
Also...before I
begin… I am in a guest house. I have a full kitchen and then three beds in
a bedroom. The bathroom and shower is
attached, as is a huge walk in closet.
The air conditioner is in the kitchen, under a kitchen counter. I ran it for a few hours the other day, but
turned it off and moved the standing fan to directed right at my face, and
slept better that way than with the AC on.
Last night, it was so fresh, I even turned off the fan for a few hours
and slept comfortably, on top of a sheet, with no sheet or cover over me. The AC is a daily fee for the entire time I
am here, take it or leave it. I am
honored to have the only room in guest housing with an AC, and will use it
responsibly, but will need to rearrange some things if it is to be of any
benefit. I think I will be able to move
the couch from the kitchen into the bedroom, and one of the single beds from
the bedroom to the kitchen. That way
I'll be able to sleep in the room with the AC if needed, and with just a fan in
the bedroom if not needed. It doubles
the price of my housing, but when I thought of it in terms of hours
moonlighting, I thought, what the heck, I'll splurge for being comfortable and
sleeping well when needed.
Ok...now back to the
email I prepared about my first week...
I have been mulling over what to say since I
arrived. I want to be honest, and yet there was so much more than what
was first apparent on the surface of things...(I'll get more into that in a
moment.)
You had requested my
musings about hospital, missionary personnel, how I was received, where I am
living in relation to hospital, the spiritual "climate" at the
hospital among patients, staff, missionaries, chaplains, and what types of
things we are caring for in the hospital, etc.
My musings about the
hospital were what made me hesitate to send an email. It is so very
different from Galmi, Niger and Kapsowar, Kenya, for that matter. There
is clinic only on Mondays, Wednesdays and Fridays, and the typical day starts
at about 8 am, and lasts until about 1 or 2 pm. I am on call two days per
week. The weekends and Tuesday and Thursday calls are 24 hours, from 7 am
till 7 am the next day, and the M/W/F call is whomever comes in after clinic
hours (so anytime between 11-2 depending on provider), until 7 am.
Whomever I admit from clinic or on call, I see until they go home.
I was on call twice so far. On my first call, Wednesday, also my
first day of clinic, I saw 4 patients in clinic (it was the equivalent of labor
day and the town buses weren't running, and everything else was closed/in party
mood) so everyone had light numbers. I will give a brief synopsis of my
patients later. I had three patients during "call." The
first was at about 8 pm, the second 11 pm, and the third 2 am. It made
for minimal sleep, but nothing was too challenging.
ER 1 - was an 8 year
old boy who was on a trampoline and fell on his brother - patient's ribs vs.
brother's knee and he has some pain with deep inspiration. There was no
obvious flail chest, breath sounds were equal bilaterally and XRay wouldn't change
my management (but would cost the family, and the hospital -the tech would have
to be paid for his travel time, and time to do the XR.) I gave ibuprofen
for pain control, and didn't think we had incentive spirometers, so gave
instructions on taking deep breaths 10 at a time, once an hour while
awake. I later saw some incentive
spirometers, but they are reserved for and reused by post-op patients.
ER 2 - was a 36 year
old woman with "mountains" of vomiting. No diarrhea, no fever.
I gave her an IM shot of promethazine, a liter of fluids, and after 500
ml she had no more nausea, no vomiting and was no longer dizzy. I wrote
out my discharge instructions and said she could go home after completing the
liter of fluids. Gave instructions to maintain po hydration, gave some po
promethazine and went to bed. I was surprised to still see her laying in
her bed when I returned to see patient number three. Transportation can be a challenge, and she
was just resting till a more appropriate hour.
By the time I arrived at 7 am for rounds, she was gone.
ER 3 - was an 18
month old with diarrhea and vomiting. Again...mountains. The family
could not quantify the number of oz of fluids she had drank that day, could not
tell me the number of wet diapers, or the number of episodes of diarrhea. (Similar
to Africa most kids don't wear diapers, but unlike Africa, diapers are used for
big, important events and trips, like going to the doctor!) I asked if
the baby had tears when she cried, and the family was shocked at the question. "No," they answer emphatically, as
if tears were a bad thing, and not a good indication of adequate hydration.
So, I have an afebrile kid whom I have watched thirstily gulp down
6 oz of fluids, and proceed to return 5 minutes later. She has a great
cap refill, but is tachycardic. I admitted her for the remaining few
hours of the morning for maintenance hydration after her bolus, and by my
morning rounds, she had no further vomiting or diarrhea and was drinking and
eating well.
Yesterday, Saturday,
I was on call and had only one patient, at about 11 am. He was a sixty
year old gentleman who had just returned from La Ceiba where he had an AKA done
four days prior. He was told he had a urinary infection and told to follow
up with us. No antibiotics were given for the patient to take at home,
and I'm not sure what was done at the hospital. He did have an ultrasound
report showing evidence of grade 1 prostatic herypertrophy. He had an infected urine, CVA tenderness, and
so I treated him for that. His diabetes was remarkably well controlled on
1000 mg metformin BID so I refilled that, his incision looked fantastic, and I
gave the family supplies to keep it clean and dressed. I also encouraged
him to accept the diagnosis of hypertension and take medication for it - he
started on the day I saw him, and his BP was 190/90. All in all he was
very pleasant, as was the family. I hate to think that a BKA would have
been sufficient, but he waited until the surgeon at our hospital was gone, so
he had to go into La Ceiba, and there they prefer to do the surgery that will
not need to be revised - an AKA. (BKA is
a below the knee amputation, and AKA is an above the knee amputation, for those
of you who prefer I explain my medical terms and use reference ranges!) :) I'm just thankful you care to read what I
write, so I'll do my part to explain what I can when I remember!)
The clinic visits
are scheduled by computer, and after completing a clinic visit, you put the
diagnosis in the computer and prescribe medications (and the computer program
shows the up to date tally of available meds and how many are available.
You search first by the drug you want, and if none is available, you can
search by class, and see what a good substitute might be. There is also a
shelf of outdated medications, which aren't in the computer, but can be
prescribed, and distributed for free. My
favorite thus far on the expired shelf is keflex. I use it all the time!
There is one OB
doctor, and he is on what nears perma-call. Only one FM doc also does OB,
and those are the OB doctor's only nights off call. I was able to deliver
my first patient on Wednesday, and have offered to care for all the laboring patients,
and do a few C-Sections with him before taking over all C- Sectiona and the OB
service as long as he is willing to be on call if I need him. No other
patients have come in in the past 4 days. I am also seeing a good number
of prenatal care patients in clinic, and I'd guess there are at least 20
patients daily that are getting routine prenatal care and plan to deliver at
the hospital. This number is growing all the time.
So...a word more
about my hesitancy to report the schedule. It just seems so meager
compared to Galmi. On the other hand, I think it will be a tremendous
blessing. There are other things to be done on Tuesday, Thursday,
Saturday and Sunday. Thursday night is a praise and fellowship night,
with a potluck. Sunday morning there is bible study, and then a church
service to follow - it is typically a sermon downloaded from the states, with
live praise music inserted before and after, and today there was a discussion
about how to practically apply it to our lives.
On Tuesdays and
Saturdays one of the missionaries goes down to the garbage dump in La Ceiba.
People live there. And, the folks with electricity, literally have
to pay rent to live at the garbage dump.
The missionary who goes talks with families, takes food, and offers
basic medical services (as a mom without any medical training would.) I
look forward to going on this excursion, but I am on call both Tuesday and
Saturday this week. Some of the missionaries teach a seminary-type class
to local pastors on Saturdays (and another day). There is also a
Children's Home at the base of the hospital, and there are ample opportunities
to play and love those kids. And, in reality I am just learning what goes
on day by day.
The other hesitation
was that arriving here was such a stark difference from arriving at Galmi.
Arriving at Galmi everyone knew your plane was landing and came to meet
you. You saw a sea of stranger's faces who would then invite you to
dinner and become friends quickly though shared time and meals. Instead
of having a smattering of lunches and dinners to get to know everyone on the
compound in Galmi, I have had a dinner with Joel's family, and one with Judy,
so that has been fine, just different.
I was
hesitant to discuss the schedule because I feel as if it is so light on the
work. With essentially just three half day clinics per week and two calls
per week. But, I remember back to what "Belle" said at a First
Wednesday meeting about wanting her time as a medical missionary to be 50%
medical, and 50% missional. That would definitely be possible here.
It seems as if a lot of the families thrive by using that as family time.
For me, I am thinking about what it could look like. Perhaps
kid-sitting so parents can go to town or have a date night. Spend time at
the children's home. Helping with the OB call. Improving my
Spanish. Reading my bible. At this point, although I feel as if the
schedule is light, I am excited to embrace it as a blessing and be a blessing.
(And next week I'll be working 5 of 7 days so we'll see if I still think
the same!) :) (Belle is a
fictional name from a Disney movie to represent a phenomenal young surgeon
missionary who has blessed Via Christi by having a relationship with us, and
coming to share her story at a monthly missions meeting we have. She is in a country that is closed to
missionaries, but is involved in healing and missions through her practice of
medicine.)
I was
welcomed at the airport by Judy, the pediatrician doing a Samaritan's Purse two
year post residency fellowship. We threw my bags in the extended cab of
her truck, and then went to the grocery store. (I packed trunks to Niger,
but I highly recommend roller suitcases for Honduras, or for travelling alone.
I was able to attach my carry-on roller suitcase onto my large checked
bag, and roll them together, and my other roller bag separately, and didn't
have to pay for anyone to help me with luggage or have any hassle or
haggle! The luggage requirements are different for Latin America vs.
Africa, and only one checked bag is allowed. I had offered to bring lots
of stuff for the missionaries and friends of the hospital, and then also
chocolates and small gifts for the missionaries, so I was happy to know that
the extra 50 lb bag would only be a $40 charge which seemed more than fair.
I was charged for luggage again, about another $40 USD to get on the
small plane from San Pedro Sula to La Ceiba, but I don't know if I had had only
the allowable luggage if there would have been a charge.) At the grocery
store we walked aisle by aisle and Judy pointed out what to get here and now,
what could be gotten later or closer, helped point out the importance of
expiration dates, the use of vinegar to clean fruits and vegetables, etc.
She even brought a cooler for me to put in frozen foods, meats, cheeses
and fruits. She showed me to my room, helped me up with my bags, and then
I was left to settle in for the night. I had plenty of groceries and was
able to make myself a suitable dinner!
The
next day, Tuesday (a day without clinic...), Joel, the FM doctor and my host
stopped by to say he was on call the night before, and had patients at odd
times to prevent him from stopping by. He said he'd be back in the
afternoon and he'd give me a tour of the hospital. I saw the exam rooms -
each of which has a desk with the computer for the schedule and prescribing as
well as internet, the exam table, a few chairs, a sink, and and AC! There
is a door to the front and back, and your patient could be waiting on either
side. The paper chart has the chief complaint and vital signs filled out,
and then there is room for exam, assessment and plan, as well as follow up
instructions. After being seen, each patient goes to the Consejeria, or
translated, Counselor. This is a visit with a chaplain, who prays with
the patient. The last stop before paying the bill is the pharmacy.
The
story of one patient was shared at Praise and Fellowship this past week - an
alcoholic man came to the ER and accepted Jesus. He sobered up during his
hospital stay, but his commitment remained. He got information on a local
church and has the support of his family. They said that story is not
uncommon and that the consejeria's role is indispensable. The Consejeria
is a mandatory stop for all patients, and if the pharmacist sees the patient
skipped that step, they are sent back!
After
the tour, I was again left to myself. I had learned to use the short wave
radio, so could have communicated with Joel or Judy, but was happy to have a
low key time to get settled in, send some emails, relax and stay in front of a
fan!
The
short wave radio is an interesting thing. It is a heavy walky-talky
shaped contraption, and the hospital main call station is 146.585. You
start by giving someone's call letters, for example, if I was going to call
Judy, I would press the talk button and say, "HR3JEB (her initials are
JEB) this is HR3MEH (my initials) or HR3HOT (the code for the hotel/guest
housing), Judy, do you copy?" Then she would reply,
"quinientos." That means that we change the station to 500, or
146.500, and there we can have a semi-private conversation. The general
radio can be used from 7 am till 9 pm, and there is a separate call station for
use overnight so as to not wake everyone up with the ER calls. At the end
of your conversation you say "QSY, 585" which I think means, over and
out, and then you switch back to the main station, 146.585.
Wednesday
was clinic and call, and a dinner with Joel and his wife and three children.
His wife works with an organization called Honduras al Mundo - Honduras
to the World, which encourages Hondurans to recognize how much they've been
blessed and helps disciple them to go abroad and serve others instead of just
allowing and expecting missionaries to come and serve them. One of their
group has gone and has possibly even met/worked with "Belle." I
was able to share some dark chocolate covered pomegranate candies, which were a
big hit!
Thursday,
I rounded on and dismissed my ob patient, her son (it is very rare to do
circumcisions here) and the other 18 month old I had admitted. Judy,
Jamie - a missionary whose husband works at the bilingual school, and I went
into La Ceiba. Our first stop was immigration. Every 90 days the
missionaries who aren't residents have to take a Visa trip and be gone for at
least two days to be allowed back into the country. Judy was leaving two
weeks after her Visa was to expire, and was able to get that adjusted, after
hours of waiting. During that time I had a wonderful chat and opportunity
to get to know Jamie, and nurse by training, but unable to work in the hospital
because she doesn't speak Spanish, so she is working on language study now.
After
paying the fees, and returning to immigration again, we were then off to run
errands. An ACE hardware that was more like a Walmart was a stop, and
then the fruit market downtown to get mangoes, bananas, cucumbers, tomatoes,
potatoes, beans, melons, onions, garlic, cabbage, etc. Then to a grocery
store, where I bought some ground hamburger and was thankful not to have to
grind it myself, like in Niger! I found a little tortilla press, in case
I get really ambitious at a variety store on our way out of town. We were
so busy all day, we forgot to eat, but a fellowship potluck was waiting when we
got back! Since we got back as the
potluck was starting, I took a bag of York Peppermint Patties, and they were
gone even before I went around the table!
Good choice!
I was
starting to feel super tired from being post call, the heat, not eating, and
having a GI bug. But, was able to sleep almost 11 hours after the praise
and fellowship, and was ready for Friday! I'm now on day 3 of antibiotics
and feeling much better. I was only cold and clammy once, only
orthostatic once and my blood pressure never got below 105 systolic, so I'm
calling that a win for my self-doctoring skills!!! :)
Yesterday
(Saturday) I stuck around since I was on call, and then had a rice wrapper
dinner with Judy and Joel's families. The rice sheets were found in San
Pedro Sula, and you stick them in hot water, and they turn into a clear -type
wrapper that we filled with lettuce, cilantro, carrots, cucumber, peppers,
avocado and then wrapped up like an egg roll and dipped in teriyaki, soy or a
peanut sauce! It was a beautiful (I wish I had taken a picture. The greens, oranges, yellows, etc were so
vivid! We'll have to do it again, if for
nothing else, a picture!) and tasty meal! Then, I had the best chocolate
chip cookie I've ever had! and also so watermelon for dessert, before cleaning
up the kitchen and dishes, and then watching Silver Linings Playbook.
(They have a stall at the mall in La Ceiba where you can buy 3 DVDs for
100 lempiras, or $5. They are often available in Honduras before they are
available at Red Box, and I would venture to say, even while they are still
in theaters, in some cases!
This
morning there was a bible study walking through the bible, and they are
currently at the beginning of Isaiah, and then church followed.
I did
laundry and hung up one shirt before being attacked by fire ants, and decided
to forgo the air/line drying for the electric dryer until those ants could be
killed. My ankles still sting and burn!
In
terms of missionary personnel -
Vance
is the OB doctor, and has brought up the numbers over the last about 2 years
that he has been around. He has a protocol sheet he printed out for me.
Essentially q 6 week visits until about 24-28 weeks, then q 4 weeks until
the q 2 week visits start at 34 weeks. There is an initial size/dates
ultrasound, and then one for anatomy between 24-28 weeks. Initial labs
include RPR, HIV, hct and blood group. Glucose screening was done, but
only rarely were they elevated, and never was a case of gestational diabetes
found over the months the testing was going on! He also works on a farm.
On the OB patient I delivered, I put in my first independent pudendal
block, which helped greatly in my second degree repair. She was a G1
(first time pregnant) and her perineum was sooo tight. I was about to do
an episiotomy, but was giving the block time to work and she was ready!
Joel
is a FM doc who worked with went to residency with Kyle Jones whom I met at
Kapsowar in Kenya! He does OB and general medicine. He has three
beautiful children. He does some pastoral teaching.
Mark
is a FM medicine doc who prefers not to do OB. He also helps
coordinate/stock/run the pharmacy. I brought out several bible study
books in Spanish for him, and he also helps with pastoral teaching.
Judy
is a pediatrician doing the Samaritan's Purse Post Residency Fellowship.
She has been a tremendous blessing for me thus far in terms of pick up,
shopping trips to La Ceiba, dinner and companionship! She also helps out with the pharmacy.
Abby
is an ER doctor who has been taught to do/invited to do/willing to do... a lot
of primary care! Including some OB and pap smears! :) Her
husband is a pilot and would like to be able to build a runway and perhaps help
improve access to health care in areas there are no roads.
There
was another doctor who has gone to London to get an MPH, and the surgeon is in
the states right now, but will be back before I leave.
Dave
is an IT wizard.
Another
family works in the shop and fixes EVERYTHING including missionary cars!
A
couple families teach at the bilingual school.
One
lady organizes the trips to the dump, arranges guest housing, etc.
I'm
sure I'm forgetting some significant folks, but, I still have a lot to learn.
How I
was received is definitely different than Niger, but I got picked up from the
airport, shopped, settled in, got a tour, and on the fourth day I was able to
meet most people at the fellowship night. It was different, but it was
fine.
There
was a medical staff meeting on Wednesday, and every week. It was good to
be there. One discussion that came up was how to assign back up to
visiting doctors. If the "host" is required to be backup, it
was mentioned that that would be a deterrent to the doctor's wanting to host.
I was not afraid to speak up and say, we know how to do most things
medically, but it would be nice to at least have a voice on the end of the
radio or phone to be able to discuss procedural things or have some advice from
a longer term expert. It was decided that I could call Joel if I needed
anything medically or Vance for OB. I may not need it, it is just really
nice to know who you can call when you get in over your head. And...in
completely new surroundings, I think that is fair!
I live
in guest housing. There is no one else here right now. There are
some rooms with kitchens, some are more like hotel rooms with just beds and
access to the large main floor kitchen. I am the lowest housing on the
hill and therefore closest to the hospital. There used to be a way to
walk across about a three story valley, but a group who had been visiting were
on it, each leaned a different direction to be in a picture, and it swung,
plunging all of them off the foot-wide pathway and into the ravine. There
were multiple injuries and even some deaths. That has been dismantled,
but will probably be replaced with a more sturdy structure within the next year
or so. Therefore, in order to get to the hospital I walk down the hill,
and then up the hill. It takes less than 5 minutes from my place.
Most of the longer-termers drive their trucks or motorcycles to the
hospital.
The
spiritual climate among the missionaries is great, deep even. Bible study
this morning was led by two young ladies, probably in their early twenties, and
they had great insights in addition to the material covered. The church
service was missionaries and a few boys from the children's home, but no staff,
and the same was true for Praise and Fellowship on Thursday night.
Some people go into the community for church services, but I
think they are in the minority.
I have
seen some OB patients and some women's health patients. When asking one
teenager who had pelvic pain and discharge if she was sexually active, she
said, oh, no, I am a Christian.
To
another 16 year old with similar complains, I asked her sister to give us a
minute alone, and she said that she had been sexually active with two partners,
and no mention of her religious beliefs, just for example. All patients
know the order of the visit - get vitals done and chief complaint
registered, then see the doctor, then see the chaplain, then to the pharmacy,
then pay the bill.
I
started out seeing my own patients right off the bat, right from the start
without shadowing anybody, so I don't know how involved the missionaries are in
their own exam rooms...
The
nursing staff has been great. When they get on the radio to tell me about
patients, they speak slowly and give me a good synopsis of why the patient is
there and what the vitals are. They have been great at starting IVs and
are quite knowledgeable of what is in the pharmacy.
So far
I've seen about 10 clinic patients, 4 in the ER, and had 3 inpatients
(including mom, baby, and kiddo admitted from the ER).
My
clinic patients have been routine - coughs and colds, vaginal pain and
discharge, multiple pretty severe UTIs with CVA tenderness and horrible looking
UAs, and quite a bit of prenatal care.
One
challenge is being a hallway and a half away from the OB doctor, making it
challenging to share the ultrasound and copy the patient's prenatal records
efficiently.
The
most intriguing patient I saw in clinic was a 40 year old who could never get
pregnant, so she had adopted children. Her first period was at the age of
12 and she was still menstruating regularly (filling in some useful info for
thinking about a diagnosis of breast cancer). Starting the night prior to
the visit she began having a discharge from her nipple. On exam, I could
feel a 4x5 cm mass at the 6 o'clock position of her breast, and squeezing this
mass produced a very thick serosanguinous discharge. It was hemoccult
positive. (Not good if thinking about
breast cancer.) We did a sono and it appeared to be a cystic mass
measuring 2 x 2 cm, and relatively well defined (finally some good news
decreasing the liklihood of breast cancer). I sent her to La Ceiba for a
mammogram, and instructed her to come back with the XRays, and report the
following week. If the mammogram is normal, we will do an ultrasound
guided drainage of the cyst. If it is suspicious, then she will stay and
receive definitive treatment.
That
is all for now!
I'm
doing well!
Please leave me a comment here or on facebook, email me, or somehow say Hi! :)
